Revised 5/ 2017 1

Revised 5/ 2017 2

Revised 5/ 2017 3

Revised 5/ 2017 4

United States Department of Agriculture Data Collection

The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race, ethnicity and sex of applicants on the basis of visual observation or surname. Applicant name: _________________________________

Date: _________________________

_______ I do not wish to furnish this information

Ethnicity:

________ Hispanic or Latino

________ Not Hispanic or Latino

Race: (Mark all that apply)

________ White

________ Black or African American

________ American Indian or Alaska Native

________ Asian

________ Native Hawaiian or other Pacific Islander

Gender: _______ Male

_______ Female

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